RCN Competences
Travel health nursing:
career and competence development
RCN guidance
Acknowledgements
Endorsements
We would like to thank all those who supported the
development of this document, especially the travel
health nurse specialists who have updated this
document and also authored the original document
(RCN 2007). They are all current members of the RCN
Public Health Forum and Fellows of the Faculty of
Travel Medicine of the Royal College of Physicians and
Surgeons of Glasgow.
The following bodies have endorsed this document
The Faculty of Travel Medicine of the Royal College of
Physicians and Surgeons of Glasgow
Health Protection Scotland
The National Travel Health Network and Centre
Jane Chiodini
Lorna Boyne
Alexandra Stillwell
Sandra Grieve
We would also like to thank Dr Michael Ingram GP,
Radlett Hertfordshire, Chairman of Conference LMCs
and a Fellow of the Faculty of Travel Medicine of the
Royal College of Physicians and Surgeons of Glasgow
who contributed his advice, guidance and support.
This document was supported by the
RCN Public Health Forum.
Suggested citation
Chiodini J, Boyne L, Stillwell A, Grieve S Travel health
nursing: career and competence development,
RCN guidance. RCN: London, 2012.
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ROYAL COLLEGE OF NURSING
Travel health nursing:
career and competence development
RCN guidance
Contents
1.
2.
3.
Foreword
2
Purpose of trip and planned activities
14
Introduction
3
Quality of accommodation
15
How to use this framework
4
Financial budget
15
Competency levels
4
Health care standards at destination
16
Producing evidence
4
Performing risk assessments
16
Using the framework flexibly
5
Conclusion
18
Travel medicine services in the UK
6
6
The competency framework for
travel health nurses
19
Introduction
Overview of the development of travel
medicine in the UK
7
19
4.
Pre-travel risk assessment
and management
10
Core competency 1: General standards
expected of all nurses working in travel
health
20
What is pre-travel risk assessment?
10
Core competency 2: Travel health
consultations
Information about the traveller
10
Core competency 3: Professional
responsibilities for nurses working
in travel health
22
Information about the traveller’s itinerary 10
Reasons for asking questions
11
5.
References
24
Age and sex
11
6.
Appendices
27
Medical history
11
13
Appendix 1: KSF dimensions
compared to RCN Core Competences
27
Previous travelling experience
Current knowledge and interest in
health risks
13
28
Travellers visiting friends and relatives
13
Appendix 2: Sample travel risk
assessment form and travel risk
management form
Previous vaccination history
13
Appendix 3: Summary of travel
health-related information sources
32
Special needs
13
- essential guidance documents
32
Destinations
13
- telephone advice lines and databases
32
Departure date
14
- useful websites
33
Length of stay
14
- travel-related organisations
33
Transport mode
14
- travel health training and education
33
1
T R A V E L H E A LT H N U R S I N G
Foreword
increasingly prominent. So much so that in 2006 the Royal
College of Physicians and Surgeons of Glasgow established
its Faculty of Travel Medicine (FTM), to which nurses were
admitted on their own merits as founder Associates,
Members and Fellows. It is anticipated that expert nurses,
as described in this document, should have the
qualifications and experience sufficient to aspire to be
admitted to this Royal College Faculty.
Travel health is a relatively new but fast growing field of
medicine, and in the UK, nurses provide the majority of
advice to travellers.
Travellers cross all boundaries, including age and ethnic
background, which makes this field of practice
increasingly more complex. Government organisations
and agencies are improving directional guidance and
advice to travellers; this is a welcome move in setting
standards for the care of travellers.
The FTM publication Recommendations for the Practice of
Travel Medicine can be used in conjunction with this
document. These documents are complementary and
together will support nurses, doctors and pharmacists in
achieving optimum practice in protecting their patients
when delivering travel health services.
Trends are changing in the UK, with increasing numbers of
people travelling to exotic and remote destinations seeking
adventure and new experiences. Imported communicable
diseases and the health of migrants within the UK
populations are areas of increasing concern, both for the
indigenous population and for non-UK born travellers
returning to their country of origin to visit friends and
relatives.
Pre-travel risk assessment and risk management underpin
the travel health consultation. For this reason, and in order
to create a wider understanding for the thousands of
health care professionals who undertake travel health
consultations and provide care, the authors felt it both
essential and useful to give a detailed description of the
concept of travel risk assessment.
As the Government’s 2010 white paper Healthy lives,
healthy people: our strategy for public health in England
highlights, such situations are important in relation to
public health and in 2012 the RCN’s Public Health Forum
2012 published Going upstream: nursing’s contribution to
public health, which includes a commentary on travel
health as related to all four UK countries.
In this updated publication a section outlining the practice
of travel medicine in the UK today has been added, and
focuses particularly on the complexity of the many issues
related to the service provided in primary care.
This updated publication contains information on the
current guidelines and standards for the care of travellers
by appropriately registered health care professionals. It
builds on the original Competencies: an integrated career
and competency framework for nurses working in travel
health medicine (RCN, 2007), which contained the first
published guidelines and standards in the field of travel
health medicine.
We hope that this document is not only informative, but
also serves as a useful aid to your practice in the exciting
field of travel medicine.
Sandra Grieve
Chair, RCN Public Health Forum
See Appendix 3 and References for further details on the
papers mentioned here.
This revised publication also aims to define the standard
that would be expected for a competent nurse,
experienced/proficient nurse and a senior
practitioner/expert nurse.While there is a strong focus on
the work of a registered nurse, the field of travel medicine
is truly multi-disciplinary and much of the information
provided in this publication is equally applicable to other
registered health care professionals, including doctors and
pharmacists who provide travel health services.
Following the introduction of formal training and
qualifications in the UK in 1995, the contribution of
nursing to the travel health agenda has become
2
ROYAL COLLEGE OF NURSING
Introduction
then determines where each job slots into the new pay
bands. Common job profiles continue to be developed and
are applicable across the UK, and where a job fits a profile
it is possible to place it straight onto an appropriate new
pay band. For the relatively few jobs that don't
automatically fit a profile, trained job evaluators drawn
from management and staff side carry out the evaluation
using a job analysis questionnaire (JAQ). Each pay band
has a number of pay points. Staff below the maximum
point can expect to progress to the next point each year.
Competence can be defined as:“The state of having the
knowledge, judgement, skills, energy, experience and
motivation required to respond adequately to the demands
of one’s professional responsibilities.” (Roach, 1992).
This integrated career and competency framework for
travel health is an important step forward for travel health
nursing. It addresses a number of political and
professional issues and initiatives, including:
●
Agenda for Change (DH, 1999)
●
need for leadership in specialist nursing
●
need for development of standards
●
NHS Plan (DH, 2000) and its equivalent in Scotland,
Wales and Northern Ireland
●
increased focus on work-based and lifelong learning
plus supervision
●
changing focus towards professional rather than
academic accreditation.
There are two points on each pay band called gateways
where staff knowledge and skills are assessed using the
knowledge and skills framework. Pay progression at the
gateways is linked to the demonstration of applied
knowledge and skills to support continuing professional
development. The presumption in the KSF is that staff will
pass through these gateways unless there are reasons as to
why they shouldn't.
For more comprehensive information on the AfC, please
refer to www.rcn.org.uk/agendaforchange. This site is your
guide to the ins and outs of the pay, terms and conditions
for the NHS. It will help you to understand AfC, how it was
developed, what you can expect in relation to pay, terms
and conditions and how you can make the most of the
system, particularly the KSF. To ask questions and debate
issues use the RCN's Discussion Zone on the membersonly area.
This edition has been updated to take account of the final
version of the NHS Knowledge and Skills Framework,
which was first published by the Department of Health in
October 2004, and the Royal College of Nursing’s
Integrated Core Career and Competency Framework,
which was published in 2010.
Agenda for Change
Agenda for Change (AfC) was implemented in the NHS
across the UK in December 2004. It was the biggest
overhaul of NHS-wide pay, terms and conditions in more
than 50 years. It applies to all NHS organisations and
therefore sets a UK framework for pay, terms and
conditions of employment.
The AfC and its knowledge and skills framework (KSF)
means that all staff will have clear and consistent
development objectives; can develop in such a way that
they can apply the knowledge and skills appropriate to
their level of responsibility; and are helped to identify and
develop knowledge and skills that will support their career
progression.
Under AfC jobs are evaluated using a bespoke NHS job
evaluation scheme. This gives each job a weighting that
3
T R A V E L H E A LT H N U R S I N G
1
How to use the framework
The 24 specific competencies are grouped into the
following themes:
Nurses operating in the field of travel health practice work in
a variety of settings, including primary care, occupational
health, NHS clinics in secondary care, private travel clinics,
the armed services, universities and schools. The scope of
practice depends on a variety of factors, which vary between
settings and the different requirements for the NHS or the
private sector, for example. Therefore, while the broadest
spectrum of practice has been included in the descriptors
and levels of practice, some elements may not be covered in
the actual role of the practitioner. However, the descriptors
and levels do provide an indication of the expected ability to
function at that level if the situation arises.
Agenda for Change – a guide to the new pay, terms
and conditions in the NHS (RCN, 2004)
●
Agenda for Change and nurses employed outside of
the NHS (RCN, 2005).
health and wellbeing (HW)
●
estates and facilities (EF)
●
information and knowledge (IK)
●
general (G).
Every competency or dimension is subdivided into four
levels, each of which is given a level descriptor. Level 1
represents basic knowledge and skills, through to Level 4
which represents the highest level of knowledge and skills.
As you move from the level of competence to experienced
and on to expert practice levels, you build on the previous
set of skills and knowledge. So, as an expert nurse you
would be able to function across the entire range of
descriptors for practice. This guidance should be used in
conjunction with the following publications:
●
●
“Every NHS KSF post outline must include an appropriate
level from each of the six Core dimensions to which will be
added a number of specific dimensions. There is no limit
to the number of specific dimensions which can be
included, but it would be unusual for a post to need more
than seven. The specific dimensions should reflect critical
aspects of the post.” (DH, 2004)
Producing evidence
You are responsible for developing your own portfolios of
evidence for each competency in order to demonstrate that
you have achieved it at the identified/desirable level. Forms
of evidence that you can use include case histories, selfappraisal via a reflective diary, 360-degree feedback,
verification of practice and structured observation of
practice.
Competency levels
The RCN competency framework mirrors the career
frameworks designed around the core functions of the
consultant nurse and the career benchmarks of the AfC
and the NHS knowledge and skills framework (NHS KSF)
and the development and review process (DH, 2004).
So, when you gather evidence it is important to consider
the following:
The AfC generic competencies expected of all health care
professionals are captured by the NHS KSF.
●
ensure you understand what the competency statement
is asking of you
1. communication
●
review any existing work that could be used
2. personal and people development
●
identify whether the existing evidence is appropriate.
For example, if you attend a study day in preparation
for carrying out a particular intervention but you have
not practised the skill in a clinical setting, your
certificate of attendance is not evidence of competence
and you will have to consider making arrangements for
supervised practice. However, if you have undergone
The six core competencies are:
3. health, safety and security
4. service improvement
5. quality
6. equality and diversity.
4
ROYAL COLLEGE OF NURSING
training and have evidence of supervised practice and
use new knowledge and skills on a regular basis the
evidence should be enough
●
consider what else you may need to do in developing
evidence, such as feedback on your practice; if you
have further development needs, are they recorded in a
personal development plan?
●
think about using evidence that covers several
competencies; one case study may demonstrate that
you have used a variety of knowledge and skills in
caring for a person.
Using the framework flexibly
While the framework provides comprehensive guidance
for nurses in travel health, it should be used flexibly in
conjunction with the RCN publications that we have
already mentioned. This will help you to determine the
scope of actual posts, individual development needs, and
pay banding. It should also take account of developing
roles as you expand in line with the changing needs and
developments in the field of travel health.
5
T R A V E L H E A LT H N U R S I N G
2
Travel medicine services in the UK
infectious diseases following foreign holidays and trips
abroad. This data would help advisers give better advice to
travellers (HPA, 2007; HPA ,2010a).
Introduction
People travel abroad for a variety of reasons, including
business trips, holidays and visits to friends and relatives.
During the first decade of the new millennium the number
of visits overseas made by UK residents peaked at nearly
70 million, and in 2006 over 9 million trips to areas outside
Europe and North America were taken.While the recent
global and domestic economic recession means these
numbers have declined in recent years (see Table 1), the
overall UK figures for overseas travel have more than
tripled since 1981 (ONS, 2010) and it is projected that
global international arrivals are expected to reach 1.6
billion by 2020 (WHO, 2011).While some travellers seek
travel health advice before they leave the UK, surveys
indicate that a significant number still do not see a health
care professional before departure (HPA, 2008).
Clearly, it is essential to make a thorough assessment of the
traveller and provide appropriate advice. However, there is
ample evidence that inadequate advice is being given to
travellers by health care professionals who are not
sufficiently trained – including malaria prevention advice
(Chiodini, 2009) – and this is having serious consequences
for the morbidity and mortality of travellers (Checkley et
al, 2012). It is also essential that travel consultations centre
on the health education of the individual traveller (Field et
al., 2010). Behaviour changes, together with the correct
administration of vaccines and malaria chemprophylaxis,
are often necessary to prevent health problems when
travelling abroad.
While travel advice is mostly given in primary care
settings, it is increasingly taking place in private travel
clinics, the occupational health sector, military settings,
universities and schools. Recently large pharmacy chain
outlets have also become involved, offering out-of-hours
provision that is more acceptable to an increasingly
demand-led service.
Disseminating the message that people need to go for
advice in a reasonable timescale before they travel to high
risk destinations is crucial to the longer term efficient and
effective delivery of travel health risk management.
Reports published by the Health Protection Agency (HPA)
indicate that far greater attention needs to be given to
recording travel histories from patients who contract
Table 1: Visits abroad by UK residents
70,000
60,000
Misc visits
50,000
Business visits
Visiting friends
and relatives
40,000
Holiday visits
30,000
20,000
10,000
2009
2010
2007
2008
2005
2006
2003
2004
2001
2002
1999
2000
1997
6
1998
1995
1996
1993
1994
1991
1992
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
0
ROYAL COLLEGE OF NURSING
Demands on travel health advisers’ time could increase yet
further if more travellers were aware of the need to seek
advice prior to departure. Those who travel to visit friends
and relatives (VFRs) in their country of origin are the
second largest group of UK travellers abroad, and
predominantly visit resource-poor countries. Evidence
shows this group presents late, if at all, tend to travel for
longer periods, and live as part of the local community
when abroad which can increase their risk of exposure to
infectious diseases.VFRs often underestimate the risk to
their health.Also, late deals at the travel agent and on the
Internet have created a newer group of travellers that may
ask for last minute advice.
registered qualification and entitles the holder to then be
admitted as an Associate of the Faculty of Travel Medicine
of the Royal College of Physicians and Surgeons of Glasgow.
This body was formed in 2006 and nurses earned the
enormous privilege to be admitted into a Medical Royal
College to Fellow, Member and Associate status, depending
on their qualifications and experience.
Nurses have been at the forefront of travel health care in
the UK since the early 1990s and the RCN was amongst the
first bodies to recognise travel health nursing as a
specialist area of practice. In 1994 the RCN Travel Health
Group – which subsequently became a special interest
group and then a forum from 2000, began to produce
newsletters and hold conferences for nurses working in the
field. Membership of the group exceeded over 5,000
members at its height, and was highly active in the support
of education and standards of nurses working in the field.
In 2010 the Travel Health Forum was merged into the
RCN’s Public Health Forum.
Overview of the development
of travel medicine in the UK
Education and professional support
Formal education in travel medicine commenced in 1995
when Dr Cameron Lockie, a GP from Stratford-upon-Avon,
researched the concept of a training course which was then
developed by the Public Health Department of the
University of Glasgow with support from a team at the
Scottish Centre for Infection and Environmental Health
(now Health Protection Scotland). From this time forward,
postgraduate diploma and masters degree courses became
available to study.
The provision of travel medicine services
in the UK
Contracting an infectious disease during a visit abroad
represents a public health risk to the population back at
home in the UK. For this reason the decision was taken in
the 1966 contract to provide certain vaccines to travellers
on the NHS.A list of potentially infectious diseases were
named under the General Practitioner (GP) Statement of
fees and allowances payable – commonly known as the
‘Red Book’ – which included infectious hepatitis (now
called hepatitis A), diphtheria, polio, paratyphoid, typhoid
and smallpox.
In 2003 Health Protection Scotland (HPS) took full
managerial and administrative control of the courses from
the University of Glasgow, in conjunction with the Royal
College of Physicians and Surgeons of Glasgow (RCPSG),
which conducted exams and awarded the diploma. The
master’s degree course was discontinued by the university,
so did not transfer over. During this period, diploma and
MSc courses were also developed by the Royal Free
Academic Unit of Travel Medicine and Vaccines at
University College London Medical School, and by the
University of Sheffield. Sadly, due to lack of demand, both
these centres have stopped running these courses. In 2011,
RCPSG took over responsibility for providing the
foundation and diploma courses in travel medicine and in
2012 the College signed an agreement with Norway,
Finland and Sweden to permit the Nordic Initiative in
Travel Medicine (NITME) to use the Glasgow Foundation
Course material in the NITME Foundation Course.
When the new General Medical Services (GMS) contract
was negotiated in 2004 it was hoped this information would
be updated to reflect the current diseases and modern
vaccines. For example, the global eradication of smallpox
was certified in December 1979 and subsequently endorsed
by the World Health Assembly in 1980 (WHO, 2001) so
vaccination is no longer required. Unfortunately, however,
this didn’t happen and so confusion regarding the complex
issue of charging has been perpetuated. This has led to
inequality of care in what should have been an NHS service,
with some deliberately manipulating the guidance to charge
in situations when this was clearly not allowed.
From May 2012 new regulations have been put into force
regarding what travel vaccines are included in the money
that GPs already receive, that is those that are included in
NHS services. They specifically recognise that smallpox
vaccine is not available for use by GP practices and that a
vaccine for paratyphoid currently does not exist. They also
Today, other short courses are available around the UK (see
the National Travel Health Network and Centre (NaTHNaC)
and TRAVAX for the most up-to-date information), but the
diploma course offered by the RCPSG remains the only
7
T R A V E L H E A LT H N U R S I N G
Red Book, some organisations assumed they could charge.
This is not the case.
refer to Hepatitis A being available on the NHS where the
risk is high and propose a link to the advice given by
NaTHNaC. For further details see Annex BA of the
Statement of Financial Entitlements (SFE) at
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digital
assets/@dh/@en/documents/digitalasset/dh_134302.pdf
The equivalent legislation in Scotland is currently being
updated (Annex J of the SFE) at
http://www.sehd.scot.nhs.uk/pca/PCA2008(M)09SFE.pdf
In the revision, individuals who provide immunisations for
travel will be directed to refer to advice on TRAVAX (Health
Protection Scotland) to help determine country-specific,
vaccine preventable disease risk and for clinical indications
to the Green Book.
There are three categories for travel vaccines:
1. Vaccines that must always be given as part of NHS
provision through GMS additional services are:
In December 2011 the British Medical Association (BMA)
published its guidance Focus on travel immunisations –
guidance for GPs. Subsequently updated in March 2012
(GPC, 2012b), this guidance (issued by the General
Practitioner Committee (GPC) of the BMA which deals
with all matters affecting NHS general practitioners)
describes clearly what can and cannot be charged for.
Further guidance from the BMA Focus on vaccines and
Immunisations (GPC, 2012d) also published in July 2012
following changes to the Regulations – Focus on travel
immunisations – guidance for GPs was also updated in July
2012 to reflect the new regulations (GPC, 2012c).
●
hepatitis A (all doses)
●
combination hepatitis A+B (all doses)
●
typhoid (both injectable and oral preparations)
●
combined hepatitis A and typhoid
●
polio (which is only available in the combined
tetanus, polio and diphtheria vaccine)
●
cholera.
2. Vaccines that cannot be given as an NHS service and
are therefore private service vaccines are:
●
yellow fever
●
Japanese encephalitis
●
tick-borne encephalitis
●
rabies for travel purposes.
3. Those that can be given as either an NHS or private
service are
Since 2004 the provision of vaccinations and
immunisations (all necessary vaccines and immunisations
as set out in Annex BA of the Statement of Financial
Entitlements (SFE)5, published on 30 April 2012) has been
an additional service within a primary care setting.A
surgery can ‘opt out’ from providing the service but if it
does so then 2% of the global sum is deducted and
arrangements must be made with another provider
(reimbursed for this work) to provide a travel service to
practice patients requiring advice. Therefore, GP practices
are contractually obliged to see patients for NHS travel
requirements and should do so within a reasonable time of
that appointment being requested, particularly with
reference to their departure date (where practicable). Thus
an appointment and relevant immunisations should be
offered to patients who are travelling – one that is within a
reasonable and clinically appropriate timescale.
●
hepatitis B
●
meningitis ACWY.
It is up to the individual practice as to whether a charge is
made or not; the regulations do not impose any
circumstances or conditions as to when these
immunisations should be given either on the NHS or
privately. The decision lies entirely with the practice as the
regulations state that they may charge not that they must
charge. The updated guidance, issued in March 2012,
acknowledged that general practices should take into
account local policies especially if they had been negotiated
with or agreed to by their local representative organisation –
the Local Medical Committee (LMC)
However, while the GPC guidance document states such
policy should be considered, it endorses the fact that
ultimately the decision still resides with the practice. For
example, monovalent hepatitis B vaccine can still be given
as an NHS vaccine to travellers where clinically indicated
(or alternatively combined hepatitis A+B vaccine where
suitable), but if given in this way, a charge for its
administration cannot be made.Alternatively, monovalent
hepatitis B vaccine can be provided as a totally private
service for travel, in which case the cost of the vaccine plus
a fee for administration of the vaccine can be charged.
Misunderstanding over travel vaccine charging is thought
to be rooted in available guidance. The Department of
Health’s Immunisation against infectious disease,
commonly known as the ‘Green Book’, is regularly updated
and advises clinically what to give and when. But while the
Red Book advised which services were funded by the NHS,
as previously explained this has not been updated and as a
result, if an immunisation is in the Green Book and not the
8
ROYAL COLLEGE OF NURSING
There is no funding in GMS for hepatitis B for travel
purposes; the vaccine can be provided on the NHS but the
practice cannot charge the traveller for administering it.
●
Private travel clinics must be registered under the Care
Quality Commission (CQC) in England. For example, a
private clinic registered with the CQC before 30
September 2010 can develop its own PGDs (MHRA,
2010) and can administer all travel vaccines in this way.
Those registering after this time need to enter into an
arrangement with an NHS body to supply and
administer medicines under a PGD as part of an NHS
funded service (MHRA, 2010). There are plans to
introduce registration in Scotland with Healthcare
Improvement Scotland (HIS), but at the time of
publication no definite date had been determined for
this. In Wales private clinics are registered with the
Healthcare Inspectorate Wales [HIW] as private health
care providers. The Regulation and Quality
Improvement Authority in Northern Ireland [RQIA]
had no requirement for registration at the time of
publication. RQIA however indicated that although
they currently had no private travel clinics in Northern
Ireland, an individual application would be dealt with
on its own merit.
●
A new development from the Department of Health
expects GP practices to be registered with the CQC in
England from April 2013 (DH, 2011).
●
Travel vaccines given within an occupational health
setting are exempt from this regulation but must
operate under their own developed Standing Orders
(MHRA, 2011).
In addition, advice must be provided as part of the NHS
service and cannot be charged for. Further useful
information can be found in the Focus on travel
immunisations – guidance for GPs document, which can
be downloaded from the BMA’s website at
www.bma.org.uk. Hepatitis B provides a particular
challenge not only for travel and the issues regarding
charging, but also in an occupational health situation.
Readers are strongly recommended to read recent BMA
guidance also published on this subject. (GPC, 2012d)
Vaccines provided within a private setting – such as a
private travel clinic or within an occupational health
setting – would not be subject to these charging issues.
Prescribing travel vaccines
The prescribing of travel vaccines is another area of great
confusion. The following information provides a basic
outline, but further reading is recommended (see
Resources section of this document).
●
In an NHS setting travel vaccines can be prescribed
either under a Patient Group Direction (PGD) for just
the NHS travel vaccines or a Patient Specific Direction
(PSD), or prescribed by a medical or non-medical
prescriber for all travel vaccines including the private
travel vaccines.
Table 2: Options for prescribing travel vaccines (based on setting). Please note, the information for a private clinic is
only relevant in England at the current time.
Setting
PGD
PSD
Medical or non medical
prescribing
Other
NHS setting for example,
GP surgery
YES for the NHS vaccines
YES if no PGD for the NHS
vaccines
YES for any vaccines
N/A
NO for the non NHS
vaccines
YES for the non NHS
vaccines
Private clinic registered
with the CQC (before 30
September 2010)
YES for all vaccines
YES if no PGDs available
(although this is less
practical)
YES
N/A
Occupational health
setting
Not required
Not required
YES if needed
Under the Standing
Orders written within the
setting
A project to review UK medicines legislation has been ongoing for some time and it is expected that this consolidated
legislation will come into force in 2012 (MHRA, 2012). For further details go to www.mhra.gov.uk
National Minimum Standards and Core Curriculum for Immunisation Training of Healthcare Support Workers (HCSWs)
has recently been published by the HPA for the administration of influenza and pneumococcal vaccines. It is not current
practice for HCSWs to administer childhood, travel or other vaccines in the UK. (HPA 2012)
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317134415868.
9
T R A V E L H E A LT H N U R S I N G
3
Pre-travel risk assessment and
risk management
Introduction
What is pre-travel risk
assessment?
This section introduces the concept of pre-travel risk
assessment, its importance in the task of evaluating and
managing the advice required to minimise the traveller’s
risk, the structure and reasons for performing
assessments, and the practical aspects of essential
documentation.
A pre-travel risk assessment entails collection of
information regarding the traveller and the nature of the
trip (see below).You will find a sample pre-travel risk
assessment form in Appendix 2 that you can adapt as
necessary.
National online databases should always be consulted for
the latest information on the country specific risks – to
help inform recommended vaccines and additional
information, for example disease outbreaks. In addition in
the UK the principal resource for travel health
professionals is the Health information for overseas travel
(the ‘Yellow Book’), published by NaTHNaC.All
practitioners should have access to these important
resources as well as the latest versions of the Green Book
(see www.dh.gov.uk/greenbook) and the UK Malaria
Guidelines (see www.malaria-reference.co.uk).
Information about the traveller:
understand what pre-travel risk assessment is and its
importance for the care of a traveller
●
understand the contents and reasoning of a pre-travel
risk assessment
●
be aware of the appropriate use of information
collected during the assessment to decide travel risk
management advice required, including relevant travel
immunisations and malaria prevention advice
●
have greater insight into the practical aspects of
pre-travel risk assessment, including documentation
of the process
●
understand the importance of using the latest versions
of national guidance, online databases, the Yellow Book,
the Green Book and the UK Malaria Guidelines (see
resources in Appendix 3)
●
age and sex
●
medical history
●
past and present
●
relevant family history
●
The learning objectives of this section are:
●
●
current health status including pregnancy status,
actual or planned
●
medication
●
any known allergies
●
previous experience travelling
●
current knowledge and interest in health risks
●
previous vaccine history
●
any special needs.
Information about the
traveller’s itinerary
have the ability to evaluate the sources of travel
information and use other appropriate up-to-date
resources in the travel health consultation.
10
●
destination(s)
●
departure date
●
length of stay
●
mode of transport
●
purpose of trip and planned activities
●
quality of accommodation
●
financial budget
●
health care standards at destination
●
relevant comprehensive insurance provision.
ROYAL COLLEGE OF NURSING
Reasons for asking questions
●
It is essential to ask a traveller questions on the topics
detailed above. Responses will influence many things,
some of which are detailed below. This knowledge will help
you to assess the risk factors and then manage that risk by
selecting appropriate health advice, vaccinations, malaria
prevention measures and advice. The following section
looks at some examples of what you should consider in a
pre-travel risk assessment.
Female travellers
● security risk possibly increased if travelling alone
●
need to be culturally sensitive in personal dress
●
if of child bearing age, need to determine that there is
no possibility of being pregnant at time of travel
vaccination administration; problems associated with
contraception; travelling while managing menstruation
and so on.
Age and sex
Young travellers
This relates particularly to children under five years old:
●
road traffic accidents and drowning incidents are the
leading causes of death in child travellers (Field et al.,
2010)
●
risk of illness such as malaria, or travellers’ diarrhoea,
which can be more severe
●
small, mobile and inquisitive toddlers, who have
limited hygiene awareness – put fingers in mouths,
touch everything – which leads to increased risk of
faecal orally transmitted illnesses and dehydration
●
rabies is more common in children than adults
(Warrell, 2012)
●
increased risk of other hazards such as sunburn and
heat exposure; careful supervision is needed
●
mortality from malaria increases with age in the UK,
elderly travellers need to be targeted for pre-travel
advice (Checkley et al., 2012).
Male travellers
● risk of accidents higher in males 20 to 29 years old
(McInnes, 2002).
Medical history
Past and present medical history and current
health status
● previous medical history may have impact on choice of
trip; for example, a person who has had spleen removed
would be at increased risk of severe illness if travelling
to destination where malaria, particularly P.falciparum,
is endemic (Chiodini et al., 2007)
●
those with ongoing medical problems may require
specialist advice; for example, those with severe renal
or liver disease would need advice regarding malaria
chemoprophylaxis
●
people who are immuno-suppressed; some live
vaccines may be contra-indicated and other vaccines
may be less effective (Salisbury et al., 2006)
●
people with pre-existing conditions such as diabetes
and coronary heart disease may have higher risk if
illness occurs at destination, increasing their risk of
needing medical attention that may be of variable
quality (the most common cause of death abroad in UK
travellers is due to coronary heart disease) (HPA, 2007)
restrictions on some choices for travel vaccines and
malaria chemoprophylaxis.
Older travellers
● immune systems reduced, more at risk of infection and
serious sequelae
●
senses reduced, more at risk of accidents
●
pre-existing medical conditions such as diabetes,
coronary heart disease often lead to complications
●
primary immunisation may not have been
administered because born prior to implementation of
national programmes
●
increasing risk of sexually transmitted diseases in the
over 50 year old age group in today’s society (HPA,
2010b)
people with epilepsy or psoriasis have reduced choice
of chemoprophylaxis for malarious endemic regions
(Chiodini et al., 2007)
●
people with a family history of relevant illness; for
example, the condition of epilepsy in a first degree
relative may influence the choice of the malarial
chemoprophylactic drug selected (Chiodini et al., 2007)
●
●
increased risk of serious adverse events following a first
dose of yellow fever vaccine in those over 60 years
(Khromava et al., 2005)
11
T R A V E L H E A LT H N U R S I N G
●
problems of counterfeit medicines found abroad
recent surgery or long term medical problem such as
respiratory disease may impact on travel and a fitness
to fly examination may be required (Aviation Health
Unit, 2012)
●
physical disability may impact on type of trip, limit
activities, and have an increased need for medical care,
which may be of variable quality
●
HIV-infected people may be denied entry into some
countries (The Global Database); if they are not denied
entry, their immune status will need to be known prior
to administration of some vaccines and for the
purpose of tailoring advice
●
problems can occur when taking drugs into other
countries, the legal status of some drugs in other
countries may be different to the UK and restrictions
are in place regarding controlled drugs; correct
paperwork, including a doctor’s letter or prescription
and any relevant licence can be helpful at the point of
entry to a country
●
elderly people on regular medication need to be aware
of the importance of continuing regular
administration despite crossing time zones,
inconvenience of diuretics and resulting diuresis
●
be aware of restrictions for carrying medication and
medical equipment on aircraft and at immigration
such as needles.
●
psychiatric history may have impact on long term
travel or expatriate lifestyle; for example, mefloquine
for malaria chemoprophylaxis is contraindicated
(Chiodini et al., 2007)
●
pregnancy increases risk from malaria; if
complications occur in the pregnancy medical
intervention may be required but reliable medical care
may not be available at the destination; deep vein
thrombosis (DVT) following a long haul flight is a
greater risk in pregnancy; the early scan should be
performed ideally before travel ; antenatal records
should always be taken on the trip; tour operators will
set individual restrictions on a pregnant woman flying
in the third trimester of the pregnancy (Aviation
Health Unit, 2012)
Allergies to drugs or food/reaction to
vaccination
● establish true anaphylactic reaction to vaccines
previously administered to avoid similar event – it
should be noted that anaphylactic reaction to vaccines
is extremely rare (Salisbury et al., 2006)
●
allergy to foods, any specific drugs or latex; for
example, establish if there is a true anaphylactic
reaction to eggs in which some of the vaccines are
manufactured
breastfeeding presents some restrictions on choice of
malaria chemoprophylaxis, some restrictions
regarding administration of live vaccines need to be
assessed
●
provide specific advice to minimise problems to severe
reactions to insect bites
●
establish previous severe adverse reactions/events to
malaria chemoprophylaxis
●
consider arrangements for the traveller to carry with
them a supply of epinephrine (adrenaline) for
emergency use where there is a history of severe
allergic reaction to an agent
●
to establish a history of, or the possibility of fainting,
enquire before administering vaccines. Fainting is
more common than anaphylaxis and practitoners need
to know the difference between the two.
●
●
determine wellbeing at the time of vaccination,
afebrile, feeling well and fit to receive vaccinations, no
possibility of pregnancy as mentioned above.
Medication
● some prescribed medication could contraindicate
malaria chemoprophylaxis or live vaccines (BNF;
Chiodini et al., 2007)
●
a woman on the oral contraceptive pill could lose
contraceptive efficacy if she suffers travellers’
diarrhoea (Field et al., 2010) specialist advice is
required for those on medication such as insulin
Previous travelling experience
●
●
safe storage of drugs in transit, particularly for drugs
that need refrigeration
●
problems generally taking sufficient supplies of
medication for an entire trip is recommended due to
12
establish previous travel experience to identify any
problems in the past; for example, difficulty in
compliance with any malaria chemoprophylaxis,
whether more prone to travellers’ diarrhoea, insect
bites and so forth
ROYAL COLLEGE OF NURSING
●
it is illegal to take girls who are British nationals or
permanent residents of the UK abroad for FGM
whether or not it is lawful in that country; suspicion of
such behaviour should be reported to the Foreign and
Commonwealth Office (FCO) (see the HPA’s Migrant
health guide).Also see the RCN’s Female genital
mutiliation: an educational resource.
deliver advice in an appropriate way so that it is more
likely to be accepted by traveller.
Current knowledge and interest
in health risks
●
establish the level of knowledge and concept of health
risks of the traveller so that appropriate travel health
advice can be given
●
consider traveller’s attitude – for example, a risk taker
or risk averse
●
establish general interest and response to advice that
may be given to encourage self-learning; for example,
suggest well regarded Internet sites to increase
knowledge further.
Previous vaccination history
●
having accurate information of previous vaccine
history status will ensure duplication of vaccines does
not occur and makes it possible to plan appropriate
schedules within the time limit prior to departure
●
gather information about primary immunisation status
to ensure complete courses were given
●
travellers should be advised to safely keep
documentation of their own vaccination record cards,
particularly if they get vaccines from different sources,
such as GPs and private travel clinics.
Travellers visiting friends and
relatives (VFRs)
●
●
●
●
●
VFR travellers have a different risk profile to other
types of travellers – tending to travel for longer, live as
part of the local community, may not seek advice prior
to travel, underestimate their health risks
Special needs
data suggests that travellers visiting friends and
relatives are less likely than other travellers visiting
Africa to take anti-malarial prophylaxis; this is possibly
because they underestimate the risk of acquiring
malaria, and do not appreciate that natural immunity
will wane after migrating to the UK; second generation
family members will have no clinically relevant
immunity to malaria (Chiodini et al., 2007)
●
identify any specific needs so that plans can be made to
ensure travel arrangements are as smooth and
convenient as possible
●
identify groups and associations that will inform and
protect travellers with special needs, such as travellers
with a disability.
Destinations
those visiting friends and relatives in countries with
endemic malaria make up the majority of cases of
falciparum malaria in the UK, but the risks of this
group dying from malaria are much smaller than for
other travellers, with most deaths occurring in tourists
(Checkley et al., 2012)
consultation with VFRs should explore their values and
beliefs and the practitioner should deliver advice
accordingly; the importance of health risks should be
stressed such as how essential it is to take appropriate
chemoprophylaxis when travelling to areas where
malaria is endemic (Neave et al., 2011)
migrants from countries with high rates of female
genital mutilation (FGM) may return to visit friends
and relatives intending their children to undergo FGM;
13
●
establish the exact destination location to determine
the disease risks; for example, yellow fever is restricted
to Africa and South America (NaTHNaC, 2010)
●
establish a specific location in a country; for example,
malaria is rarely present in Nairobi in Kenya, but it is a
high risk in other parts of the country, for example
Mombasa (NaTHNaC, 2010)
●
record stopovers in case the destination may have
impact on the risk assessment regarding immigration
requirements
●
rural areas may be of greater risk than urban,
particularly for diseases such as malaria and Japanese
B encephalitis; in an emergency situation, especially in
more remote areas, it may be difficult to reach medical
help e.g. in the event of a potentially rabid wound
T R A V E L H E A LT H N U R S I N G
●
●
●
●
location may also impact on other risks such as road
accidents; developing countries may have inadequately
constructed roads, limited road safety rules and poorly
maintained vehicles
Transport mode
accidents may be a greater risk and poor standards in
health care facilities may mean an inadequate
provision of care and an inability to cope with injuries
consider the political and cultural issues at the
destination and observe any UK Foreign Office travel
restrictions (see the Foreign Commonwealth Office)
●
long haul travel is most commonly by air, but travel by
sea and overland journeys should also be taken into
account when assessing individual risk
●
risk of travel-associated complications due to
prolonged periods of immobility while travelling, such
as DVT should be considered for travellers who have
any pre-disposing factors (Field et al., 2010)
●
any pre-existing medical condition or situation may
raise concerns about fitness to travel, and an
examination prior to the trip may be necessary; for
example, following a myocardial infarction (as long as
there are no complications) travel is not advised for
7-10 days. (Civil Aviation Authority 2012). Individual
airlines may vary on required intervals.
●
cruise ship travel is increasingly popular, particularly
with older people; issues for consideration could
include: yellow fever vaccination for entry into some
countries; risk of disease outbreaks such as influenza
and norovirus; and physical problems such as sea
sickness (Field et al., 2010).
areas at high altitude may have unknown effects on
travellers who have not been at altitude before; this is
particularly a concern for people with pre-existing
medical conditions; specialist referral may be required
(Field et al., 2010).
Departure date
●
departure date will affect the time for giving advice
and the timing of vaccine schedules
●
seasonality of certain diseases will affect advice to
travellers; for example, Japanese B encephalitis has a
seasonal risk from May to October in northern areas of
South East Asia, and influenza may be endemic in the
southern hemisphere during UK summer months
●
Purpose of trip and planned
activities
travellers who attend a travel advice consultation very
late may not have time to receive optimum pre-travel
advice or protection; however, it is never too late to
commence some vaccine protection or provide malaria
chemoprophylaxis and receive appropriate advice to
take additional precautions – for example, food, water
and personal hygiene advice.
●
people travel for many reasons and it is important to
establish the reason because this impacts on the risks
and type of pre-travel health advice given
●
holiday makers may take risks that they would not at
home because they are relaxed and want to enjoy the
experience without always considering the risks
involved; package tours generally provide a reasonable
amount of security, and that can lead to excessive
complacency or over indulgence; this is particularly
true for all-inclusive holidays that are aimed at younger
age groups where limitless alcohol is available for
consumption (Hughes et al., 2011)
●
backpackers and people undertaking more
adventurous travel or expeditions may travel for longer
periods of time and venture to areas where tourism is
less well-developed; they may undertake risky
activities such as camping in areas where malaria is a
high risk, and where other mosquito-borne diseases
are transmitted in the daytime such as yellow fever and
dengue fever; they also often take part in activities that
can be hazardous such as scuba diving, water sports
like white water rafting, bungee jumping, and trekking;
facilities may not be designed to the same standards as
Length of stay
●
generally the longer the duration of stay, the greater the
travel health risks (Field et al., 2010)
●
longer stays may run into seasons where risk is either
higher or lower for certain diseases
●
travellers are sometimes less cautious on a long stay,
and this may increase the personal health risk; for
example, relaxing adherence to malaria
chemoprophylaxis
●
advice on the use of malaria chemoprophylaxis is
different for long-stay travellers and the practitioner
may need specialist knowledge (Field et al., 2010).
14
ROYAL COLLEGE OF NURSING
those in the UK, and the quality of equipment and
supervision may not be adequate (Field et al., 2010)
●
those travelling for the purpose of a pilgrimage for
example, Umrah and Hajj, are at greater risk of
diseases resulting from close association such as
respiratory disease and meningococcal meningitis;
certificate of proof of vaccination for ACW135 and Y
will be required by these pilgrims to obtain a country
entry visa
http://www.hajinformation.com/main/p10.htm
●
people working abroad face special risks depending on
their type of work; for example, medical personnel
working in disaster areas, or security workers going to
war zones will be at greater risk of disease of close
association and the blood borne infections (Field et al.,
2010)
●
business travellers under great pressure, making
frequent short term and/or long haul trips can
experience loneliness, isolation, and a cultural divide;
this group of travellers can be at risk from excessive
alcohol use and casual sex (Patel, 2011)
●
●
●
Medical tourism
● a growth area in recent years, with people travelling for
many types of surgery including dental treatment,
cosmetic surgery, elective surgery and infertility
treatment; in 2008 an estimated 52,500 UK residents
travelled abroad for medical treatment (NHS, 2011a);
the most common problems travellers experience
when travelling abroad for treatment result from
undertaking limited initial research, booking
treatment without a proper consultation, aftercare,
travel risks (for example, deep vein thrombosis and
pulmonary embolism), lack of insurance, and poor
communication and language difficulties (NHS,
2011b); guidance is available from the NHS Choices
and the Foreign and Commonwealth Office websites
(FCO, 2012).
Quality of accommodation
expatriate travellers can also have similar experiences;
they miss family, have difficulties with language
barriers and suffer psychological stress (Patel, 2011)
people travelling to visit friends and relations are at
greatest risk from diseases such as malaria because
they don’t fully understand the risks; they have
incorrect, pre-conceived ideas that they have natural
protection against the disease, and may stay longer at
hazardous locations such as rural areas (Field et al.,
2010)
●
good quality air conditioned hotels will reduce some
health risks, but travellers should be advised not to be
complacent about hygiene standards especially for
food preparation
●
screened accommodation gives better protection than
none in an area with malaria, but travellers should be
advised about other personal protection biteprevention measures for night-time and daytime
●
camping and living fairly rough will increase travel
health risks.
Financial budget
travellers are more adventurous today and advice must
emphasise and focus on, for example, risk of accidents,
environmental hazards and STIs.
Social activities
● forced marriage is an abuse of human rights, a form of
violence against women and men, where it affects
children, child abuse and where it affects those with
disabilities abuse of vulnerable people (FCO, 2011); of
cases referred to the Forced Marriage Unit, 85 per cent
involve women, although men can also be victims and
should be given the same assistance and respect when
they seek help (HM Government, 2009).
15
●
budget often dictates the quality of eating places, but
food hygiene is not always guaranteed in an expensive
venue
●
generally, travellers should be advised not to eat food
from street vendors because of hygiene standards and
the quality and storage of the food used; however,
sometimes the reverse is true if it is possible to observe
the thorough cooking of fresh food at high
temperatures
●
backpackers often have to manage their trip within a
tight budget and need to be aware of the increased risk of
using cheaper forms of transport, living in poorer
accommodation, and having less money for medical help
●
all travellers should make it a priority to buy
comprehensive travel insurance before travelling, and
always carry details of policy documents with them;
T R A V E L H E A LT H N U R S I N G
●
special attention should be given to the pregnant
traveller’s insurance including cover of the foetus for
situations such as premature delivery and subsequent
care of the baby
controversial, time-consuming, and may make
practitioners vulnerable to litigation (Genton and Behrens,
1994).
practitioners need to be flexible and provide sufficient
information to help the traveller to prioritise in
situations where limited time or finances mean that
the optimum recommendations cannot be followed.
How to conduct a risk assessment
It is better to carry out a risk assessment using one of the
methods below rather than trying to recall the necessary
questions from memory.With practise, risk assessment
information collection can be carried out effectively
without taking excessive time. Interpretation of the
information and applying advice and recommendations
appropriate to the individual risk assessment is the time
consuming part of the consultation.
Health care standards at
destination
●
where health care standards are in any way in doubt at
a destination, it is essential not only to take out travel
health insurance but cover for medical repatriation as
well
●
people with a pre-existing medical condition,
particularly if it is serious, should consider the
suitability of destinations where standards of health
care are poor and sparse; check that travel insurance
will cover in such situations, and, if possible, check
medical facilities in advance
●
people travelling to an area where facilities may be
inadequate should consider travelling with a first aid
kit and sterile needle pack.
1. Ask the traveller to complete a form prior to the
consultation that can then be reviewed by the travel
health adviser before the appointment and used to
identify any potential problems. This may save time in
a consultation, and identify availability of vaccines
which may require ordering in advance or preparation
of a patient specific direction. However, within the
consultation the nurse still needs to review the
completed form to ensure the traveller has understood
the questions asked and confirm the information
provided by the traveller is accurate, which will include
reviewing the medical records if available. This may
not be as time saving as originally thought, but it does
give the traveller some idea of the depth of information
required about the trip and helps to make the nurse
feel more prepared. Information can be collected on
paper for scanning into the computer system, or within
an online form on a website accessible to the general
public, for example, a general practice surgery website.
Performing risk assessments
Performing risk assessments are dependent on the
individual practitioner, their facilities and how
comprehensive the service is. The main consideration is to
allocate sufficient time to perform the risk assessment and
deliver appropriate travel risk management advice. It
would be unsafe to allow only 10 minutes for a new travel
appointment.A minimum of a 20-minute consultation
appointment per person should be allowed to exercise best
practice. Travellers with more complex needs – such as
backpackers, or individuals requiring malaria prevention
advice relevant to their destination – may need a longer
consultation time. The Nursing and Midwifery Council
‘Code’ is about being professional, about being accountable
and about being able to justify your decisions; employers
need to respect the complexity of a travel consultation and
appreciate that sufficient time must be allowed for a nurse
to abide by the Code.
2. Complete the risk assessment form with the traveller at
the consultation, identifying any foreseeable problems
and issues which may require further questioning. The
travel health adviser will be assessing the risk with no
prior knowledge of the trip details, which can be more
time consuming. It is therefore helpful to collect
information about the traveller’s destination, date of
departure and duration of stay when the appointment
is initially booked to support this method.Again, the
risk assessment can be done on paper and subsequently
scanned into the computer system, although designing
a computer template for the process may be more
helpful and ultimately time efficient.
3. A risk assessment could be performed by following a
checklist to ensure all information is collected and the
detail is fully documented on the traveller record.
However this method is less reliable or efficient, is very
time consuming, and great care needs to be taken to
ensure all the information is documented.
Face-to-face contact with the traveller is the preferable way
to undertake a travel risk assessment and provide advice.
In general, providing advice via a telephone or e-mail is
16
ROYAL COLLEGE OF NURSING
Steps to follow after a risk assessment
●
Once a risk assessment has been undertaken and in
conjunction with reference to an online national travel
health database (plus other resources outlined in
Appendix 3) it is possible to ascertain:
●
the disease risks that may be a potential threat to the
traveller
●
the non-disease related risks the traveller may be
exposed to, such as accidents
●
which vaccine-preventable diseases the traveller may
need protection against
●
which vaccines should be given and which schedules
are most appropriate
●
identification of any contra-indications to vaccination
and the relevant information to be given to the traveller
about the vaccines including efficacy, length of
protection, schedule, side-effects and cost implications;
details of clinical information can be obtained from
the Summary of Product Characteristics (SPC) in the
Electronic Medicines Compendium
●
if malaria prevention advice is required; if it is and if
chemoprophylaxis is recommended then the
appropriate information about the available choices,
efficacy, side-effects and cost need to be incorporated
into the advice given; details of clinical information
can be obtained SPC in the Electronic Medicines
Compendium
●
the most appropriate general travel health advice that
should be given
●
the necessary special travel health advice that should
be given, tailored to the traveller’s individual needs; for
example, if the traveller has diabetes
●
if certain travellers should be advised against travelling
to a destination because of extreme health risk; for
example, pregnant women, infants and young children
travelling to a destination with a high risk of malaria
and where there is chloroquine drug resistance to
Plasmodium falciparum malaria
●
the additional information sources which could be
given to the traveller to aid self-directed learning;
travellers should take on a degree of responsibility for
self-education, and it would be ideal if some of the
health risk review occurred prior to the travel health
consultation (see the FCO’s Know Before You Go
campaign)
if the traveller understands the information given to
obtain informed consent to vaccination (Salisbury et
al., 2006)
Documentation to accompany the travel
consultation
● the NMC’s Standards for medicines management
(NMC, 2010) and Guidance for record keeping for
nurses and midwives (NMC, 2009) should be followed
at all times
17
●
the nurse is responsible for undertaking and
evaluating the risk assessment, and thoroughly
documenting it in a professional manner and keeping
records secure
●
a risk management form is provided in Appendix 2 to
highlight the information that could be documented
during the travel health consultation; while it may be
considered necessary to adapt this content to suit your
individual workplace, please note items included are
indicative of best practice. For example, the form
suggests that in addition to discussing potential side
effects from the vaccines, the Patient Information
Leaflet (PIL) from the packaging or from
www.medicines.org.uk/emc/ could be given. Guidance
from the National Prescribing Centre (NPC, 2009)
identifies that a medicine supplied via a PGD must
legally be accompanied by the statutory PIL.When a
medicine is administered via a PGD it is good practice
to provide the PIL to the patient at the time of
administration, although this is not a legal
requirement. Please study the information on the risk
management form carefully
●
information about vaccine administration should be
well documented in full and records held for 10 years
for an adult and 25 years for a child or eight years
following a child’s death (NaTHNaC, 2010). Records
should include the name of the drug, batch number,
expiry date, site of administration and name of the
administrator. The details of the administration of
yellow fever vaccination must be kept for a minimum
of 10 years, and if a yellow fever centre ceases to
operate, then arrangements must be made for the
records to still be available for 10 years after
registration ceases
●
provide a written record of vaccinations administered,
and advise the traveller to keep the documentation safe
and take to any future travel health consultations; these
records will help travel health advisers and aid future
decisions on vaccine requirements
T R A V E L H E A LT H N U R S I N G
●
it may be useful to write a protocol documenting the
process of a travel consultation setting out items such
as aims and objectives, key resources to be used, roles
of staff involved, description of the process of booking
appointments, the travel consultation, planned audit,
and so forth.
Conclusion
No travel health consultation should take place without
conducting a travel risk assessment and documenting the
information. The assessment forms the basis of all
subsequent decisions, advice given, vaccines administered
and the malaria prophylaxis advice that is offered. This
takes time to perform correctly, and for best practice
practitioners should leave sufficient time as described.
18
ROYAL COLLEGE OF NURSING
4
The competency framework for travel
health nurses
Core competency 1: General standards expected of all nurses working in travel health
Competent nurse (level 5)
Experienced/proficient nurse
(level 6)
Senior practitioner/expert nurse
(level 7)
Fulfils points at this level
Fulfils points at level 5 as well
Fulfils points at levels 5 and 6 as well
4. Revises and updates established
protocols
5. Makes clinical decisions in more
complex scenarios. For example,
patient over 60 years-of-age
travelling to a country endemic for
yellow fever.
4. Oversees effective implementation of
protocols and make recommendations.
5. Works independently to make clinical
judgements and decisions.
12. Participates in the revision and
updating of established PGDs /
PSDs or standing orders.
12. Oversees effective implementation of the
PGDs/PSDs standing orders.
1. Acts in accordance with the NMC Code as a registered
nurse.
2. Keeps up-to-date and is aware of relevant nursing issues.
3. Applies evidence-based research to clinical practice.
4. Works to established protocols.
5. Works with access to supervision to make clinical
judgements for routine travel health scenarios.
6. Works effectively as a team member.
7. Maintains authentic records of advice and procedures.
8. Provides accurate and consistent advice to travellers.
9. Knows where and how to access information and seek
further advice.
10. Recognises and act on any inability to cope or lack of
knowledge or skills.
11. Refers to a more specialist service as and when
appropriate, using appropriate mechanisms.
12. Works with the patient group directions (PGDs) patient
specific directions (PSDs) prescription from a medical or
non medical prescriber or standing orders (in the
occupational health setting).
Applicable KSF dimensions
1
2
3
4
5
6
7
8
9
10
11
12
Core 1, Core 5
Core 2
Core 5
Core 5
Core 5, HWB2, HWB6, HWB7
Core 5
Core 1, Core 5
Core 1, Core 5, Core 6, HWB1, HWB4
Core 5, IK3
Core 2
Core 5, HWB2, HWB6
Core 3, Core 5, HWB2, HWB5
9. Refers to more specialist services in
unusual circumstances.
Applicable KSF dimensions
4 Core 4, Core 5
5 HWB1, HWB2, HWB4, HWB7
12 Core 4, Core 5, IK3
19
Applicable KSF dimensions
4
5
9
12
Core 4, Core 5
HWB1, HWB2, HWB4, HWB7, IK2
Core 1, Core 5, HWB2, HWB6
Core 3, Core 4, Core 5
T R A V E L H E A LT H N U R S I N G
Core competency 2: Travel health consultations
Competent nurse (level 5)
Experienced/proficient nurse
(level 6)
Senior practitioner
/expert nurse (level 7)
Fulfils points at this level
Fulfils points at level 5 as well
Fulfils points at levels 5
and 6 as well
2. Supports and educates other team members in the
process of risk assessment.
3. Selects or develops appropriate risk assessment
tools.
4a. Provides support and advice to inexperienced
colleagues in complex problems.
4b. Interprets risk assessment where advice is not
straight-forward.
4c. Manages some more complex issues
independently but refers when necessary. For
example, travellers with serious underlying
medical conditions.
2. Develops protocols
encompassing risk
assessment. For example,
for travel health
consultations, malaria
prevention advice, vaccine
storage.
3. Interprets risk assessment
in unusual or special
circumstances.
4. Accepts referrals for more
complex issues.
1. Demonstrates good geographical knowledge and know
how to access further information regarding global
destinations including use of an up-to-date atlas and
accessing the Internet for such resources.
2. Performs a comprehensive risk assessment and know how
to carry out risk assessment effectively.
3. Interprets the risk assessment and accesses the latest
recommendations for travel health advice, immunisations
required and malaria chemoprophylaxis appropriate to the
risk assessment for the journey.
4. Recognises complex issues beyond personal scope and
knows who to contact for further information, support and
advice.
5. Checks if UK childhood immunisation schedules are up-todate and acts appropriately if not.
6. Demonstrates knowledge of the common travel related
illnesses for example, travellers’ diarrhoea, hepatitis A,
hepatitis B, typhoid, malaria and dengue fever (consider
MMR, flu and pneumococcal disease in relation to travel)
and other travel-related hazards.
7. Provides individual advice to the traveller regarding:
• accident prevention and the importance of adequate
travel insurance
• safe food, water and personal hygiene protective
measures
• prevention of blood-borne and sexually transmitted
diseases
• general insect bite prevention
• prevention of animal bites particularly rabies including
wound management
• prevention of sun and heat complications
• personal safety and security
• malaria-awareness, bite prevention, appropriate
chemoprophylaxis and the importance of compliance
and symptoms of malaria to quickly diagnose and treat
a traveller with the disease.
8. Communicates information effectively to explain the
disease and other travel-related risks, vaccine
recommendations and malaria prevention advice
appropriate to the risk assessment.
9. Prioritises appropriately in situations where a patient’s
time or financial situation does not allow the optimum
recommendations.
10. Assesses anxieties, especially to vaccination, and acts
appropriately.
11. Demonstrates an excellent vaccine administration
technique.
12. Completes patient and administrative records after
vaccination.
6. Disseminates their knowledge of travel-related
diseases such as rabies, Japanese encephalitis,
tick borne encephalitis, yellow fever,
schistosomiasis, West Nile virus, tuberculosis.
7a. Advises travellers with complex travel and special
needs. For example, the pregnant traveller, the
traveller with diabetes, immunosuppression,
cardiac or respiratory disease, those who have
experienced previous severe adverse reactions to a
vaccine.
7b. Advises travellers on more complex health issues.
For example, emergency standby malaria
medication, post-exposure prophylaxis following
blood-borne virus exposure such as medical
electives, management of altitude sickness.
7c. Meets the standards required for administration of
yellow fever vaccine and complies with national
regulations as a Yellow Fever Vaccination Centre,
which is under the administration of National
Travel Health Network and Centre (NaTHNaC) in
England, Wales and Northern Ireland and Health
Protection Scotland (HPS) in Scotland.
8. Provides specialist advice to travellers with more
complex itineraries that may also require the
prescription, provision and administration of more
unusual vaccines such as Japanese B encephalitis,
rabies, tick-borne encephalitis and BCG.
9. Demonstrates involvement in the financial
governance of travel including vaccine
administration, which vaccines are provided
privately and their cost, and which vaccines are
reimbursable under the NHS. This would also
include the provision of malaria chemoprophylaxis,
medication in anticipation of illness abroad and
travel health products such as mosquito nets.
11. Administers intradermal vaccinations if required.
20
7. Writes appropriate travelrelated advice sheets on all
topics of travel health
advice, where advice
sheets are not readily
available
8. Provides advice on more
complex issues at a
national/board/strategic
level.
ROYAL COLLEGE OF NURSING
Applicable KSF dimensions
1
2
3
4
5
6
7
8
9
10
11
12
Core 2. Core 5, IK3
Core 2, Core 3, HWB2, HWB6
Core 3, Core 5, HWB3, IK2
Core 2, IK3
Core 3, Core 5, HWB2, HWB5, HWB6, HWB7, IK2
Core 2. Core 5, IK2
Core 2, Core 5, IK2
Core 1, Core 2
Core 3, Core 5, HWB1, HWB2, HWB3,
Core 6, HWB1, HWB2, HWB4
Core 3, Core 5, HBW5
Core 1
Applicable KSF dimensions
2
3
4a
4b
4c
6
7a
Core 2
Core 3, Core 4
Core 1, Core 2
IK2
Core 3, Core 5
Core 2
Core 1, Core 3, Core 5, HWB1,
HWB4
7b Core 1, Core 3, Core 5, HWB1,
HWB4
7c Core 2, Core 5
8 Core 1, Core 3, Core 5, HWB1,
HWB2, HWB3, HWB4, HWB5,
HWB7, IK2
9 Core 4, Core 5, Core 6
11 HWB5
21
Applicable KSF dimensions
2
3
4
7
8
Core 4, Core 5, HWB1
Core 3, IK2
Core 1, Core 4, Core 5
Core 1, Core 5, HWB1, HWB4, IK3
Core 4
T R A V E L H E A LT H N U R S I N G
Core competency 3: Professional responsibilities for nurses working in travel health
Competent nurse (level 5)
Experienced/proficient nurse
(level 6)
Senior practitioner /expert nurse
(level 7)
Fulfils points at this level
Fulfils points at level 5 as well
Fulfils points at levels 5 and 6
as well
1. Attends annual training session on immunisation as
specified in the Health Protection Agency national
curriculum programme.
2. Attends annual update on anaphylaxis and CPR training.
3. Understands the issues of informed consent and acts
accordingly.
4. Ensures that travel health knowledge is always up-to-date.
5. Evaluates own care practices against accepted standards
and guidance.
6. Attends an annual travel health update study
session/conference at a local, national or international
event.
7. Uses recognised online databases on a frequent and
regular basis to ensure the latest national
recommendations are always followed and read the
update information to ensure awareness of issues such as
disease outbreaks.
8. Demonstrates awareness of and uses a variety of other
recognised travel health resources online (see appendix 3).
9. Joins an organisation that provides regular travel health
information and contact for example, the RCN Public
Health Forum, Affiliate membership of the Faculty of Travel
Medicine of the Royal College of Physicians and Surgeons
of Glasgow or the British Global and Travel Health
Association.
10. Demonstrates evidence of learning to apply skills and
knowledge in the field of travel medicine. For example,
minimum of 15 hours of relevant learning plus mentorship
in clinical skills before undertaking a travel consultation
alone.
11. Insists on adequate time to perform the travel
consultation and negotiating sufficient time if this has not
been permitted.
12. Demonstrate adherence to the principles of vaccine
storage, administration and related theory.
13. Ensures adequate vaccine stock control, ordering or
delegating this process to ensure sufficient stock is
available at all times as per local protocols.
14. Is involved in the choice of vaccine products used in
relation to clinical evidence and best practice and does not
necessarily accept the decision of non-clinicians ordering
products based on cost and profit margins alone.
15. Works effectively with non-clinical staff who are involved
in the travel consultation process.
16. Complies with audit procedures and policy changes.
5. Evaluates own care and acts as a
resource to other nurses in ensuring
their care is evaluated against
accepted standards and guidelines.
9. Considers joining the International
Society of Travel Medicine (ISTM),
and/or Associate Membership of the
Faculty of Travel Medicine of the Royal
College of Physicians and Surgeons of
Glasgow.
10a. Considers formal travel medicine
training at post graduate level.
10b. Acts as a mentor to competent nurse
Level 5.
11. Negotiates the provision of travel to be
managed in a clinic setting but with the
availability of some additional
appointments as well.
5a. Uses expert knowledge to inform
protocol development and guide
others in this process.
5b. Audits documentation to ensure
appropriate standards and guidance is
maintained.
5c. Appraises individuals on progress as
required.
6a. Educates nurses working in the field of
travel health.
6b. Speaks/presents research at travel
medicine educational events at a
national level/international level.
7. Uses international databases to ensure
awareness of global issues in travel
health.
9. Is involved at national and
international level in travel health,
including committee membership of
relevant forums. Aspires to becoming a
Member or Fellow of the Faculty of
Travel Medicine of the Royal College of
Physicians and Surgeons of Glasgow.
10a. Demonstrates highly developed
specialist knowledge of the whole
range of topics in travel medicine.
10b. Acts as a mentor to competent nurse
Level 5 and Experienced/proficient
nurse level 6.
10c. Contributes to the evidence base for
travel health nursing practice to
support and promote travel health
nurses.
10d. Identifies areas for further research.
14. Takes responsibility for deciding which
vaccines are to be used.
15. Manages non-clinical staff in a clinic
setting.
16. Assists in the collation and
development of audit in travel health
clinical practice.
22
16. Undertakes clinical audit in travel
health practice and acts on findings to
develop and improve standards of
care.
ROYAL COLLEGE OF NURSING
Applicable KSF dimensions
Applicable KSF dimensions
Applicable KSF dimensions
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
5
9
10
11
14
Core 2, Core 4, Core 5
Core 2, Core 5
Core 2, Core 5
Core 1, Core 4, Core 5, G5
Core 3, Core 5, G3(3)
15
Core 1, Core 2, Core 4, Core 5,
G5, G6
Core 4, Core 5
5a
5b
5c
6a
6b
7
9
10a
Core 2, Core 5
Core 2, Core 5
Core 5
Core 2, Core 5, IK2
Core 2, Core 5
Core 2, Core 5
Core 2, Core 5, IK3
Core 2, Core 5, IK3
Core 2, Core 5
Core 2, Core 5
Core 3, Core 4, Core 5
Core 2, Core 3, Core 5
Core 5, G3(3)
Core 5, IK2, G3(3)
Core 1, Core 5
Core 4, Core 5
16
23
Core 2. Core 4. Core 5
Core 5
Core 1, Core 2, Core 4, Core 5, G6
Core 2
Core 1, Core 2, Core 4
Core 2, Core 4, Core 5, IK2, IK3
Core 1, Core 2, Core 4
Core 1, Core 2, Core 3, Core 4,
Core 5, HWB1, HWB2, HWB3, HWB4,
HWB5, HWB6, HWB7, HWB10
10b Core 2, Core 4, Core 5
10c Core 4
16 Core 1, Core 4, Core 5, G5
T R A V E L H E A LT H N U R S I N G
5
References
Care Quality Commission GPs and primary medical
service, London: CQC.Available from:
www.cqc.org.uk/organisations-we-regulate/gps-andprimary-medical-services (Accessed August 2012).
Foreign and Commonwealth Office (2011) What is a forced
marriage?, London: FCO.Available from
www.fco.gov.uk/resources/en/pdf/2855621/what-isforced-marriage.pdf (Accessed August 2012).
Checkley AM, Smith A, Smith V, Blaze M, Bradley D and
Chiodini PL,Whitty CJM (2012) Risk factors for mortality
from imported falciparum malaria in the United Kingdom
over 20 years: an observational study, British Medical
Journal, 344:e2116.Available from:
www.bmj.com/content/344/bmj.e2116/rr/576544
(Accessed August 2012).
Foreign and Commonwealth Office (FCO) Know before
you go campaign.Available from:
www.fco.gov.uk/en/travel-and-living-abroad/about-kbygcampaign/ (Accessed August 2012).
General Practitioners Committee (2012) Focus on travel
immunisations: guidance for GPs, London: BMA.Available
from:
www.bma.org.uk/images/focustravelimmunmar2012_tcm
41-212255.pdf (Accessed August 2012).
Chiodini J (2009) The standard of malaria prevention in
UK primary care, Travel Medicine and Infectious Disease, 7
(3), pp. 165-168.
General Practitioners Committee (2012a) Focus on
hepatitis B immunisations: guidance for GPs, London:
BMA.Available from: www.bma.org.uk/practical-supportat-work/doctors-as-managers/managing-yourpractice/focus-hepatitis-b-immunisations (Accessed
August 2012).
Chiodini JH,Anderson E, Driver C, Field VK, Flaherty GT,
Grieve AM, Green AD, Jones ME, Marra FJ, McDonald AC,
Riley SF, Simons H, Smith CC, Chiodini PL
Recommendations for the practice of travel medicine,
Travel Medicine and Infectious Disease, 10, pp. 108-128,
London: Elsevier.
General Practitioners Committee (2012b) Focus on travel
immunisations: guidance for GPs, (March 2012), London:
BMA.Available from:
www.bma.org.uk/images/focustravelimmunmar2012_tcm
41-212255.pdf (Accessed August 2012).
Chiodini P, Hill D, Lalloo D, Lea G,Walker E,Whitty C and
Bannister B (2007) Guidelines for malaria prevention for
travellers from the United Kingdom, London: Health
Protection Agency.Available at:
www.hpa.org.uk/Publications/InfectiousDiseases/TravelHe
alth/0701MalariapreventionfortravellersfromtheUK/
(Accessed August 2012).
General Practitioners Committee (2012c) Focus on travel
immunisations: guidance for GPs, (July 2012), London:
BMA.Available from: www.bma.org.uk/practical-supportat-work/doctors-as-managers/managing-yourpractice/focus-travel-immunisation (Accessed August
2012).
Civil Aviation Authority (2012) Assessing fitness to fly:
guidelines for health professionals from the Aviation
Health Unit, UK Civil Aviation Authority, London: CAA.
Available from:
www.caa.co.uk/docs/923/Fitness_To_Fly%20%20March%202012.pdf (Accessed August 2012).
General Practitioners Committee (2012d) Focus on
vaccines and immunisations: guidance for GPs, London:
BMA.Available
Department of Health (2007) Immunisation against
infectious disease – ‘The Green Book’ – 2006 updated
edition, London: DH. Updated chapters available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_079917 (Accessed
March 2012).
from: www.bma.org.uk/practical-support-atwork/doctors-as-managers/managing-yourpractice/focus-vaccinations (Accessed August 2012).
General Practitioners Committee (2010a) About the
General Practitioners Committee (online statement 12
October 2010). Available at:
www.bma.org.uk/representation/branch_committees/gen
eral_prac/Hubukgeneralpractitionerscommittee.jsp#.T1d
PNPFs65I (Accessed August 2012).
Department of Health (2010) Healthy lives, healthy people:
our strategy for public health in England, London: DH.
Available from: www.dh.gov.uk (Accessed August 2012).
Department of Health (2011) Delay to CQC registration for
GP practices (press release,August 12 2011), London: DH.
Available from:
http://mediacentre.dh.gov.uk/2011/08/12/delay-to-cqcregistration-for-gp-practices/ (Accessed August 2012).
General Practitioners Committee (2010b) Patient Group
Directions and Patient Specific Directions in general
practice (guidance issued 10 August 2010), London: BMA.
24
ROYAL COLLEGE OF NURSING
from:http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_
C/1317134415868. (Accessed August 2012)
Available from:
www.bma.org.uk/health_promotion_ethics/drugs_prescri
bing/pgdandpsdingp.jsp#.T1dbEvFs65I (Accessed August
2010).
Healthcare Improvement Scotland (HIS). See
www.healthcareimprovementscotland.org (Internet)
(Accessed August 2012).
Genton B and Behrens R (1994) Specialized travel
consultation part II: acquiring knowledge, Journal of
Travel Medicine, 1 (1), pp. 13-15.
Hughes K, Bellis MA, Calafat A, Blay N, Kokkervi A,
Boyiadji G, do Rosario Mendes M and Bajcarova L (2011)
Substance use, violence and unintentional injury in young
holidaymakers visiting Mediterranean destinations,
Journal of Travel Medicine, 18 (2), pp. 80-89.
HM Government (2009) Multi-agency practice guidelines:
handling cases of forced marriage, London: FCO.Available
from: www.fco.gov.uk/resources/en/pdf/3849543/forcedmarriage-guidelines09.pdf (Accessed August 2012).
Khromava AY, Barwick Eidex R,Weld LH, Kohl KS,
Bradshaw RD, Chen RT and Centron MS (2005) Yellow
fever vaccine: an updated assessment of advanced age as a
risk factor for serious adverse events, Vaccine, 23 (25),
pp.3256-3263.
Joint Formulary Committee (2011) British national
formulary [online], London: BMJ Group and
Pharmaceutical Press. Current edition available at:
www.bnf.org/bnf/index.htm (accessed August 2012).
The Global Database on HIV-Specific Travel and Residence
Restrictions [online resource].Available from:
www.hivrestrictions.org/ (Accessed August 2012).
McInnes R.J,Williamson, LM and Morrison A (2002)
Unintentional injury during foreign travel: a review,
Journal of Travel Medicine, 9 (6), pp. 297-307.
Healthcare Inspectorate Wales (HIW).Available from:
www.hiw.org.uk/ (Accessed August 2012).
Medicines and Healthcare products Regulatory Agency
(2010) Patient Group Directions in the private, prison and
police sectors, London: MHRA.Available from:
www.mhra.gov.uk/Howweregulate/Medicines/Availability
prescribingsellingandsupplyingofmedicines/Exemptionsfr
omMedicinesActrestrictions/PatientGroupDirectionsinthe
privatesector/index.htm (Accessed August 2012).
Health Protection Agency (2007) Foreign travel-associated
illness: England, Wales and Northern Ireland – 2007
report, London: HPA.Available from:
www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/120418618
2561 (Accessed August 2012).
Health Protection Agency (2008) Foreign travel-associated
illness – a focus on those visiting friends and relatives:
2008 report, London: HPA.Available from:
www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/123141980
0356 (Accessed August 2012).
Medicines and Healthcare products Regulatory Agency
(2011) Occupational health, London: MHRA.Available
from:
www.mhra.gov.uk/Howweregulate/Medicines/Availabilityp
rescribingsellingandsupplyingofmedicines/Exemptionsfro
mMedicinesActrestrictions/Occupationalhealth/index.htm
(Accessed August 2012).
Health Protection Agency (2010a) Foreign travelassociated illness – a focus on travellers’ diarrhoea: 2010
report, London: HPA.Available from:
www.hpa.org.uk/web/HPAwebFile/HPAweb_C/128714638
0314 (Accessed August 2012).
Medicines and Healthcare products Regulatory Agency
(2012) Project to consolidate and review UK medicines
legislation, London: MHRA.Available from:
www.mhra.gov.uk/Howweregulate/Medicines/Overviewof
medicineslegislationandguidance/Projecttoconsolidateand
reviewUKmedicineslegislation/index.htm (Accessed
August 2012).
Health Protection Agency (2010b) STIs on the increase in
the over 50s (press release, 12 September 2010), London:
HPA.Available from:
www.hpa.org.uk/ProductsServices/LocalServices/EastMid
lands/EastMidlandsPressReleases/emids100913Sexualhea
lthweekover50s/ (Accessed August 2012).
Meslin FX (2005) Rabies as a traveler’s risk, especially in
high endemicity areas, Journal of Travel Medicine, 12 (1),
pp.s30-s40.
Health Protection Agency (2012a) Migrant health guide –
travel to visit friends and relatives, London: HPA.Available
from:
www.hpa.org.uk/web/HPAweb&Page&MigrantHealthAuto
List/Page/1281954639016 (Accessed August 2012).
National Prescribing Centre (2009) Patient group
directions (December 2009): a practical guide and
framework of competencies for all professionals using
patient group directions, Liverpool: NPC.Available from:
www.npc.nhs.uk/non_medical/resources/patient_group_
directions.pdf (Accessed August 2012).
Health Protection Agency (2012b) National Minimum
Standards and Core Curriculum for Immunisation Training
of Healthcare Support Workers, London: HPA.Available
25
T R A V E L H E A LT H N U R S I N G
National Travel Health Network and Centre (2010) Health
information for overseas travel: ‘Yellow Book’, Field VK,
Ford L. and Hill DR (editors), London: NaTHNaC.Available
from: www.nathnac.org/yellow_book/YBmainpage.htm
(Accessed August 2012).
(Accessed August 2012)
Patel D (2011) Occupational travel, Occupational medicine:
in-depth review, 61 (1), pp.6-18.Available from:
http://occmed.oxfordjournals.org/content/61/1/6.full.pdf+
html (Accessed August 2012).
Neave P,Allwood D and Behrens R (2011) Does
community subsidised malaria chemoprophylaxis reduce
imported malaria? A case control study of policy,
International Society of Travel Medicine Conference
(CISTM 12) 8-12 May 2011, Boston [Free Communication
FC01: Malaria and other parasitic infections].Available
from:
www.istm.org/Documents/Members/MemberActivities/m
eetings/congresses/cistm12/CISTM12Free%20Communication%20Abstracts.pdf (Accessed
August 2012)
The Regulation and Quality Improvement Authority,
Northern Ireland. See www.rqia.org.uk (Internet).
Royal College of Nursing (2007) Competencies: an
integrated career and competency framework for nurses
working in travel health medicine, London: RCN.
Royal College of Nursing (2012) Going upstream: nursing’s
contribution to public health, London: RCN.Available
from: www.rcn.org.uk (Accessed August 2012).
Toovey S, Jamieson A and Holloway M (2004) Traveler’s
knowledge, attitude and practices on the prevention of
infectious diseases: results from a survey at Johannesburg
International Airport, Journal of Travel Medicine, 11 (1),
pp. 16-22.
NHS Choices (2011a) Treatment abroad Q&A. Online
information resource available from:
www.nhs.uk/livewell/treatmentabroad/pages/questionsan
danswers.aspx (Accessed August 2012).
Vivancos R,Abubakar I and Hunter PR (2010) Foreign
travel, casual sex and sexually transmitted diseases:
systemic review and meta-analysis, International Journal
of Infectious Diseases, 14 (10), pp.e842-e851.
Available from:
www.sciencedirect.com/science/article/pii/S120197121002
3556 (Accessed August 2012).
NHS Choices (2011b) The risks of treatment abroad.
Online information resource available from:
www.nhs.uk/Livewell/Treatmentabroad/Pages/Risks.aspx
(Accessed August 2012).
Nursing and Midwifery Council (2008) The Code:
standards of conduct, performance and ethics for nurses
and midwives, London: NMC.Available from: www.nmcuk.org/Publications/Standards/ (Accessed August 2012).
Warrell MJ (2012) Current rabies vaccines and prophylaxis
schedules: preventing rabies before and after exposure,
Travel Medicine and Infectious Disease, 10 (1), pp.1-15.
Available from:
http://download.journals.elsevierhealth.com/pdfs/journal
s/1477-8939/PIIS147789391100130X.pdf (Accessed
August 2012).
Nursing and Midwifery Council (2009) Record keeping:
guidance for nurses and midwives, London: NMC.
Available from: www.nmc-uk.org/Documents/
Guidance/nmcGuidanceRecordKeepingGuidanceforNurses
andMidwives.pdf (Accessed August 2012).
World Health Organization (2001) Smallpox: fact sheet,
Geneva: WHO.Available from:
www.who.int/mediacentre/factsheets/smallpox/en/
(Accessed August 2012).
Nursing and Midwifery Council (2010) Standards for
medicine management, London: NMC.Available from:
www.nmc-uk.org/Documents/Standards/
nmcStandardsForMedicinesManagementBooklet.pdf
(Accessed August 2012).
World Health Organization (2011) ‘Health risks and
precautions: general considerations’, in International travel
and health 2010, Geneva: WHO.Available from:
www.who.int/ith/ITH2010chapter1.pdf (Accessed August
2012).
Office for National Statistics (2010) Travel trends: 2010
edition, Newport: ONS.Available from:
www.ons.gov.uk/ons/rel/ott/travel-trends/2010/traveltrends-2010.pdf (Accessed August 2012).
World Tourism Organization (2012) International tourism
to reach one billion in 2012 (press release, 16 January
2012), Madrid: UNWTO.Available from:
http://media.unwto.org/en/press-release/2012-0116/international-tourism-reach-one-billion-2012
(Accessed August 2012).
Office for National Statistics (2012) Overseas travel and
tourism – December 2011 (Statistical Bulletin), Newport:
ONS.Available from:
www.ons.gov.uk/ons/dcp171778_255239.pdf (Accessed
August 2012).
Office for National Statistics (2012) Measuring National
Well-being - What we do, 2012, Newport: ONS.Available
from: www.ons.gov.uk/ons/dcp171766_258996.pdf
26
ROYAL COLLEGE OF NURSING
6
Appendices
Appendix 1: KSF dimensions compared to RCN Core competences
The NHS knowledge and skills framework dimensions compared to the RCN Core competences levels for travel health
specialist competences.
NHS knowledge and skills framework dimension
Level 5
Level 6
competent nurse experienced/
proficient nurse
Level 7
senior practitioner/
expert nurse
Core 1
Communication
3
3
4
Core 2
Personal and people development
3
3
4
Core 3
Health, safety and security
2
3
4
Core 4
Service improvement
2
2
4
(level higher than identified in
RCN Core competences)
Core 5
Quality
2
3
3
Core 6
Equality and diversity
3
3
4
1
3
3
Specialist dimensions
HWB1
Promotion of health and wellbeing and prevention of
adverse effects to health and wellbeing
HWB2
Assessment and care planning to meet people’s
health and wellbeing needs
3
3
4
HWB3
Protection of health and wellbeing
1
2
3
HWB4
Ability to address health and wellbeing needs
2
3
4
HWB5
Provision of care to meet health and wellbeing needs
3
3
4
HWB6
Assessment and treatment planning
3
3
4
HWB7
Interventions and treatments
3
3
4
IK2
Information collection and analysis
2
2
3
IK3
Knowledge and information resources
2
3
4
G3
Procurement and commissioning
3
3
2
(level higher than identified in
RCN Core competences)
(dimension not identified for competent
nurses RCN Core competences)
G5
Services and project management
-
3
3
G6
People management
-
3
4
(level higher than identified in
RCN Core competences)
27
T R A V E L H E A LT H N U R S I N G
Appendix 2: Sample travel risk assessment and travel risk management forms
Travel risk assessment (form A) – to be completed by traveller prior to appointment.
Name:
Date of birth
Address:
■
Male
■ Female
Telephone number:
Mobile number:
Email:
Please supply information about your trip in the sections below
Date of departure:
Total length of trip:
Country to be visited
Exact location or region
City or rural
Length of stay
1.
2.
3.
Have you taken out travel insurance for this trip?
Do you plan to travel abroad again in the future?
Type of travel and purpose of trip – please tick all that apply
□ Holiday
□ Staying in hotel
□ Backpacking
□ Business trip
□ Cruise ship trip
□ Camping/hostels
□ Expatriate
□ Safari
□ Adventure
□ Volunteer work
□ Pilgrimage
□ Diving
□ Healthcare worker
□ Medical tourism
□ Visiting friends/family
Additional information
Please supply details of your personal medical history
Yes
Are you fit and well today
Any allergies including food, latex, medication
Severe reaction to a vaccine before
Tendency to faint with injections
Any surgical operations in the past, including e.g. your spleen or
thymus gland removed
Recent chemotherapy/radiotherapy/organ transplant
Anaemia
Bleeding /clotting disorders (including history of DVT)
Heart disease (e.g. angina, high blood pressure)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal (stomach) complaints
Liver and or kidney problems
HIV/AIDS
Immune system condition
Form devised and created by Jane Chiodini © March 2012
28
No
Details
ROYAL COLLEGE OF NURSING
Yes
No
Details
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions?
Women only
Are you pregnant?
Are you breast feeding?
Are you planning pregnancy while away?
Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?
Please supply information on any vaccines or malaria tablets taken in the past
Tetanus/polio/diphtheria
MMR
Influenza
Typhoid
Hepatitis A
Pneumococcal
Cholera
Hepatitis B
Meningitis
Rabies
Japanese Encephalitis
Tick Borne Encephalitis
Yellow fever
BCG
Other
Malaria tablets
Any additional information
Travel risk assessment form devised in conjunction with resources below.
1. Chiodini J, Boyne L, Grieve S, Jordan A. (2007) Competencies: An Integrated Career and Competency Framework for Nurses in Travel
Health Medicine. RCN, London. www.rcn.org.uk
2. Field VK, Ford L, Hill DR, eds. (2010) Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK.
www.nathnac.org
Form devised and created by Jane Chiodini © March 2012
29
T R A V E L H E A LT H N U R S I N G
Travel risk management (form B)
For health professional use only in conjunction with travel risk assessment Form A
Patient name:
Date of birth:
Childhood immunisation history checked:
Additional information:
National database consulted for travel vaccines recommended for this trip and malaria chemoprophylaxis (if required):
NaTHNaC:
TRAVAX:
Disease protection advised
Other:
Yes
Disease protection advised
Yes
Malaria Chemoprophylaxis
Recommendation
BCG/Mantoux
Influenza
Atovaquone/proguanil
Cholera
Meningitis ACWY
Chloroquine only
Dip/tetanus/polio
MMR
Chloroquine and proguanil
Hepatitis A
Rabies
Doxycycline
Hepatitis B
TBE
Mefloquine
Hepatitis A+B
Typhoid
Proguanil only
Hepatitis A + Typhoid
Yellow fever
Emergency standby
Japanese Encephalitis
Other
Weight of child:
Yes
Vaccine and General Travel Advice required/provided
Potential side effects of vaccines discussed
Patient Information Leaflet (PIL) from packaging or from www.medicines.org.uk/emc/ given
Patient consent for vaccination obtained:
■
verbal
■
written
Post vaccination advice given:
■
verbal
■
written
General travel advice leaflet given (all topics below in the surgery/clinic advice leaflet ) and patient asked to read entire
leaflet due to insufficient time to advise verbally on every topic:
Items ticked below indicate topics discussed specifically within the consultation:
Prevention of accidents
Mosquito bite prevention
Personal safety and security
Malaria prevention advice
Food and water borne risks
Medical preparation
Travellers’ diarrhoea advice
Sun and heat advice
Sexual health & blood borne virus risk
Journey/transport advice
Rabies specific advice
Insurance advice
Other specific specialised advice / information given on:
e.g.smoking advice for a long haul flight; altitude advice; prevention of schistosomiasis etc.
Source of advice used for further information:
NaTHNaC
TRAVAX
OR no additional specialised advice given ■
Form devised and created by Jane Chiodini © March 2012
30
Other
Yes / No
ROYAL COLLEGE OF NURSING
Additional patient management or advice taken following risk assessment – for example
● Vaccine(s) patient declined following recommendation, and reason why
● Telephoned NaTHNaC or TRAVAX for advice or used Malaria Reference Laboratory fax service
● Contacted hospital consultant for specific information in respect of a complex medical condition
● Identified specific nature/purpose of VFR travel
Authorisation for a Patient Specific Direction (PSD)
Following the completion of a travel risk assessment, the below named vaccines may be administered under this PSD to
Name
dob:
Post vaccine records
Name of Vaccine
Dose and schedule
Batch number
Signature of Prescriber
Site given
RA
RL
RA
RL
RA
RL
RA
RL
RA
RL
LA
LL
LA
LL
LA
LL
LA
LL
LA
LL
RA
RL
LA
LL
Date
Post Vaccination administration
Vaccine details recorded on patient computer record (vaccine name, batch no., stage, site, etc.)
Y/N
SMS vaccines reminder or post card reminder service set up
Y/N
Travel record card supplied or updated
Y/N
Travel risk management consultation performed by: (sign name and date)
Form devised and created by Jane Chiodini © March 2012
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T R A V E L H E A LT H N U R S I N G
Appendix 3: Summary of travel health-related information sources
Essential guidance documents
The UK Malaria prevention guidelines
All practitioners providing a travel health service should
use an up-to-date atlas, either hard copy or online (for
example, http://maps.google.co.uk/).
Chiodini P, Hill D, Lalloo D, Lea G, Walker E and Whitty C
(2007) Guidelines for malaria prevention for travellers
from the United Kingdom, London: HPA. Available from:
www.hpa.org.uk/Publications/InfectiousDiseases/TravelHe
alth/0701MalariapreventionfortravellersfromtheUK
The ‘Green Book’
National immunisation training guidelines
Department of Health (2007) Immunisation against
infectious disease – ‘The Green Book’ – 2006 updated
edition, Salisbury D, Ramsay M and Noakes K (editors),
London: DH. Updated chapters available from:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_079917.
Health Protection Agency immunisation training
resources, available at:
http://www.hpa.org.uk/EventsProfessionalTraining
Atlas
Recommendations for the practice of travel medicine
Chiodini JH, Anderson E, Driver C, Field VK, Flaherty GT,
Grieve AM, Green AD, Jones ME, Marra FJ, McDonald AC,
Riley SF, Simons H, Smith CC, Chiodini PL
Recommendations for the practice of travel medicine,
Travel Medicine and Infectious Disease, 10, pp. 108-128,
London: Elsevier.
UK immunisation policy
Health Protection Agency (2011) Routine childhood
immunisation schedule (2012). Available online from:
www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListDa
te/Page/1204031508623.
International guidance
Health Protection Agency (2010) Vaccination of
individuals with uncertain or incomplete immunisation
status. Available online from:
www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/119494740
6156.
The US Yellow Book
Centers for Disease Control and Prevention (2012) CDC
Health Information for International Travel 2012, New
York: OUP. Available from:
wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm
World Health Organization – WHO Vaccine Preventable
Disease Monitoring Systems. Use the country profile
selection centre to view the international vaccination
schedule. Database is available from:
http://apps.who.int/immunization_monitoring/en/globals
ummary/ScheduleSelect.cfm.
World Health Organization
World Health Organization (2012) International travel and
health 2012, Geneva: WHO. The current edition is available
from: www.who.int/ith/en/index.html.
Immunization Action Coalition (IAC). You can download
or view the IAC’s Quick chart of vaccine-preventable
disease terms in multiple languages from:
www.immunize.org/catg.d/p5122.pdf.
The UK Yellow Book
National Travel Health Network and Centre (2010) Field
VK, Ford L and Hill DR (editors), Health information for
overseas travel – ‘The UK Yellow Book’, London:
NaTHNaC. Available from:
www.nathnac.org/yellow_book/YBmainpage.htm.
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ROYAL COLLEGE OF NURSING
TRAVAX www.travax.nhs.uk
Telephone advice lines and databases for
health professionals
World Health Organization (WHO) www.who.int/ith
Malaria Reference Laboratory
●
Download a risk assessment form from: www.malariareference.co.uk.
●
Complete and return by fax to 020 7636 0248.
●
Receive a faxed reply within three working days.
World Health Organization (WHO) Disease Outbreak
News www.who.int/csr/don/en/
Travel-related organisations
British Global and Travel Health Association (BGTHA)
www.bgtha.org
Faculty of Travel Medicine of the Royal College of
Physicians and Surgeons of Glasgow www.rcpsg.ac.uk
National Travel Health Network and Centre
(NaTHNaC)
International Society of Travel Medicine (ISTM)
www.istm.org
Telephone advice line 0845 602 6712
available 9am-12 noon and 2pm-4pm weekdays
www.nathnac.org
Royal College of Nursing Public Health Forum (RCNPHF)
www.rcn.org.uk
TRAVAX
Telephone advice line 0141 300 1130
available from 2-4pm Monday and Wednesday,
9.30-11.30am Friday. www.travax.nhs.uk
Travel health training and education
For a comprehensive up-to-date list of courses from basic
to diploma and a variety of study days, conferences and
recommended reading, go to:
Useful websites
British National Formulary (BNF) www.bnf.org
www.nathnac.org and look on Health Professionals
homepage for ‘Training and conferences’
Centers for Disease Control and Prevention, USA (CDC)
www.cdc.gov/travel
www.rcn.org.uk and look on the Public Health Forum
Community
Department of Health (DH) Green Book
www.dh.gov.uk/greenbook
www.travax.nhs.uk and look in Resources
Electronic Medicines Compendium (EMC)
www.medicines.org.uk/emc
http://www.rcpsg.ac.uk/travel-medicine/about-ftm.aspx
Diploma and foundation distance learning courses for UK
and overseas students.
Fit for Travel www.fitfortravel.nhs.uk
Foreign and Commonwealth Office (FCO) www.fco.gov.uk
Health Protection Agency (HPA) www.hpa.org.uk
HPA Malaria Reference Laboratory (MRL)
www.malaria-reference.co.uk
MASTA www.masta.org
National Travel Health Network and Centre (NaTHNaC)
www.nathnac.org
NHS Choices www.nhs.uk
ProMED Mail (the global reporting system for reporting
outbreaks of infectious diseases)
http://apex.oracle.com/pls/otn/f?p=2400:1000
33
The RCN represents nurses and nursing, promotes
excellence in practice and shapes health policies
September 2012
RCN review date September 2015
RCN Online
www.rcn.org.uk
RCN Direct
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0345 772 6100
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